HomeMy WebLinkAbout3333 BREA CANYON RD (8)WOitKLRS' CObfl'ENSATION DL•CLARATfON
I hereby a(firm tha[ f have a certificate of Consent io self
insure, or a certificate of 1Vorkers' Compensa[ion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
O Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
Uate Applican[
C6R71FICATE OF EXESIPTION FliOhf WORKL•'RS'
COhiPEN5AT10N [I SURANCE
This section need not be complctcd if Uie work invoivcd
hy the permit is for one hundred.dollars (SI00) or IessJ
1 certify [hat in the performance of ihe work for vhich this
permit is issued, I shall not employ ny person in any manner
so as to 1 ecome subject to the Wpr rs' C mpensa o y Laws.
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Uate pplicant
NOTICE TO APPLICANT: If, after makin8 Ihis Certificate of
EaemDt n, you shoulJ become suUject [o the 15'orkers'
Compensa[ion provisions of the La6or Code, you must for[b-
with comyly with suet provisions or this permit sha11 ba
Seemed revokeJ.
LICLNSED COYTRACTORS DtiCLARAT]ON
I hereby affirm ihat [ am iicensed under prorisions of Chap[ef
9(commencing with Section 7000) of Divisinn 3 of the Dusi-
ness and Professions Cude, and my license is in fuli force anJ
effect.
License Number Lic. Class
Contractor Date
I am ezemp[ from ihe censing requirements as I am a
licensed archi[ect or a registered professional engineer
acting in my professional capaciry (Section 705t, Dus-
iness and Professions Code).
Lic, or Reg. No. Uate
liOhlL• OWNER-6UILDER DECLARATfON
f hereby affirm that I am exempt from Ihe Contractar's
License Law tnr t6e following mason (Sec[ion 7031.5, 6usi•
ness and Professions Code):
I, as owner uf Ihe property, or my emp loyees with
wages as their sole cumpensaiion, will do the vork
und the s[ruc ure is not intended or offereJ for sale
Section 7044, Uusiness and Professions Cude).
1, as owner of he property, am exclusively conirac[ing
with IicenseJ contracfors to construc[ the project
Section 7044, 6usiness and Yrofessions Code).
CONSTI2UCTIDN LGNUING AGtiNCY
1 hereby affirm that Ihere is a construetion lending agency
foc ihe performance of [he wurk for vhich this permi[ is
issued SSec. 3097, Civ. C.).
Lender s Name
LendePs Address
1 certify that I have rcad ti is applica[ion and sta e that the
above information is correcL I gree Io complY vith all County
ordinances and Sta[e laws rela ing Cu building conSlruciion,
und hgreby au[horize re resenta[ires of this County tu enicr
upun iq e abuve-lpention yfoper[y for inspe ion 1mrposes.
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Signatureotl'ermittee Date
Eeo E. Z.Bo, APPLICATION FOR GRADING PERMIT
COUNTY OF LOS ANGELES BUILDING ANU SAFETY
FOR APPLICANTTO FILL IN ., , A ooaess
y--
W' `.=+ \' ., . 1
ITE J,l/,li LI:J %iS 1 I:r l. F R'/`4 I,J LOCALITY `'. . .. -`\'
UMBERS gLOCK NEARES7 `• ` ,.` _ anCC CrRFFTi.'• . . .. .. . . ._ - . 1
teER T` IU',
NER 'Y.i F F.i li4 F'; P r. :
aess n L,^Y 1 1. : (7.r)
YA%!_A/(l'p" ;r;lr'. No'%S1.'>IJ5 t
yllt' STATE
iINEER '
F REG. NO.
IL2RE5S
V N Ol.
VTRACTORr/''`!` NO
DRESS
PROPOSED USE OF GRADED SITE(SI
Fr_f t'^uU•.;' l J IU',
CHECK IF SUPERVIS D GRA NG ( /." (''f"`
OF APPLICANT ' 'VY!i , ' ri-/y'r'''J
AD RESS
f
No -1 7'';;f
SVFiETY$ , j BOND
BOND ! % r;•.•1 . NO: II ' :` /1 f
SURETY
4
COMPANY. •
DATE • FiEC' fFILED Ii/ ' BY -'
CASH REC' OATE
EPOSITS eV FILED
THIS IS Q LIMITED TIME PERMIT
ALL WORK AU7HORIZED MUST BE COMPLETED BY
TIME LIMIT:
EXTENDEO TO: BY:
EXTENDED T0= BY:
Permit Fee
Issuance Fce
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SEE IiEVEIiSG FOR EXYLANATORY LANGUAGE
DISTRICT NO. IMAP NO. I 1
CUBIC VOS.
HANDLED:
1, 1
USE ZONE SPECIAI
CONDITIONS
FINALDATE
VALIDATION
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